Children’s Medical Report

When and for what?

Any previous hospitalizations or operations?

If others, what/when?

Please describe:

Does the child have any physical disabilities:

Please describe

Any mental disabilities?

Signature of Parent or Guardian(Required)

B. Physical Examination:

This examination must be completed and signed by a licensed physician, his authorized agent currently approved by the N. C. Board of Medical Examiners (or a comparable board from bordering states), a certified nurse practitioner, or a public health nurse meeting DHHS standards for EPSDT program.

A. Medical History

B. Physical Examination:

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